Cardiovascular Disease Flashcards
What are the major causes of cardiovascular disease?
Atherosclerosis
Thrombo-embolism
Vasculitis
What are the non-modifiable risk factors for Cardiovascular Disease?
Gender (males more than females)
Age (males over 40 or females over 50 post menopause)
Race (african american or asian)
Family History
What are the modifiable risk factors for Cardiovascular Disease?
HTN Tobacco use Elevated blood glucose Physical inactivity Overweight and obesity Cholesterol/lipids (less than 180 is optimal)
True or False: Recent evidence demonstrates that atherosclerosis is a dynamic chronic inflammatory condition
True
What are the characteristics of atherosclerosis?
- slow progressive disease
- starts in 2nd and 3rd decade of life
- very long incubation period
- often undetectable (even w/ moderate and high grade)
- initially plaques are sparsely distributed
- increase in number and size over time
- can affect ANY artery
What is the role of endothelial cells?
How does this role change when subjected to various stressors such as injury or infection?
produce antithrombotic molecules to prevent blood clots and modulate the immune response by resisting leukocyte adhesion and therefore inhibiting inflammation
Endothelial cells can produce prothrombotic molecules, secrete chemokines, and produce cell surface adhesion molecules
What is the primary event in plaque initiation?
Endothelial dysfunction
What is endothelial dysfunction?
When endothelium becomes procoagulant vs. anticoagulant and local adhesion of molecules such as leukocytes, T cells, platelets, macrophages, and foam cells (made by macrophages engulfing oxidized LDL) is associated with secretion of cytokines and growth factors, this transmigrates molecules into arterial walls
What characterizes the fatty streaks developmental stage of atherosclerosis?
lipid filling smooth muscle cells
What are the most common sites of atherosclerotic build-up?
branch points in main arteries which are subjected to turbulent flow as opposed to laminar flow
How does fibrous plaque begin to build up in arterial walls?
lipoproteins transport/deposit LDLs into the arterial intima and the fatty streaks are covered by collagen and calcium deposits form a grayish fibrous plaque on the wall
The result is narrowing of the vessel lumen
What can continued inflammation in an arterial wall result in?
plaque instability, ulceration, and rupture
when lipid core is exposed to the blood stream, platelets accumulate, and a thrombus forms
result is narrowing of lumen or thrombo-embolotic event
What is the pathophysiology of atherosclerosis?
- endothelial dysfunction
- inflammatory process involving many cellular markers within the lesion
- deposits of fatty streaks initiating event
- lesions occur in large and medium sized vessels
- maybe present throughout a person’s life-time
What are some of the major complications from atherosclerosis?
- Stroke from embolism or thrombus
- Coronary artery disease from MI, unstable angina, or ischemia
- renal artery disease or stenosis
- anuerysms
- peripheral artery disease
What is peripheral vascular disease (PVD)?
a slow and progressive circulation disorder caused by narrowing, blockage, or spams in a blood vessel
PVD may involve ANY of the blood vessels outside of the heart
What are some common clinical findings in patients with PVD?
- intermittent claudication (most common symptoms) which is predictable and reproducible
- pallor on elevation
- dependent rubor (blood pooling in maximally dilated capillary bed)
- impaired capillary refill
- impaired peripheral pulses
- cyanosis
- cool to the touch
- numbness or tingling in affected area
What arteries do you get pressure readings from in the ankle-brachial index?
brachial artery, posterior tibial artery and dorsalis pedis artery on both upper and lower extremities (go from one brachial down to ipsilateral ankle, then to contralateral ankle, and finally finish with the opposite arm you started with)
What does an ankle-brachial index measurement of .9 indicate?
What does an ankle-brachial index measurement of .5-.8 indicate?
What does an ankle-brachial index measurement of less than .5 indicate?
ABI
What is a normal refill time for capillary beds in the fingers for a capillary refill test?
less than two seconds
What is a carotid bruit and what does it indicate?
sound made by turbulent flow vibrating against arterial wall
indicates the presence of an arterial lesion/plaque
What is a turgor test?
pinching the skin and then releasing it
normally skin would return to resting immediately but in dehydrated patients it is delayed (may also observe hypotension, tachycardia, orthostatis, irregular heart rate and ECG)
What are the clinical implications for PVD?
- monitor hemodynamics during exercise
- pts w/ intermittent claudication usually have some sort of walking impairment that has shown to improve greatly with exercise
- exercise has been shown to be just as effective as surgery in reducing symptoms and improving walking distances
- pts should be instructed in proper footcare, footwear, and hygiene
- might improve nocturnal pain by elevating head of bed slightly
True or False: Exercise for claudication is different than most therapeutic exercise in the fact that the patients needs to exert themselves to the point of feeling pain in order to get maximum benefits
True
Which training type is most effective for treating patients with claudication?
What should the initial workload be?
interval training w/ short rest periods for relief of claudication
3 x/week with an initial intensity that induces claudication within 3-5min
continue this workload until pain is of moed severity (5/10)
What is raynaud’s syndrome?
Vasospasm causing reduced blood flow
What are anuerysms?
How are they classified?
What are common causes?
tears in the arterial wall
classified by cause, size, and shape
atherosclerosis, congenital infections, Marfans
What are the risk factors for aneurysms?
- CVD and associated CVD risk factors (especially smoking)
- males
- genetics (marfans)
- 40-60 yrs old
- hypertension prevalent
What are the three types of aneurysms?
Sacculuar aka Berry-small, spherical 1-1.5 cm (most common in brain tissue)
Fusiform-gradual more progressive
Dissecting-blood filled channel within aortic wall
What are the signs of an abdominal aortic aneurysm?
- dull, tearing ache/pain in low back, groin, or mid abdomen
- chest pain
- weakness or transient paralysis of legs
- palpable, pulsating (Heart beat) abdominal mass >3cm
- absent or decreased peripheral pulses aka pulse deficit
- tachycardia
What is chronic venous insufficiency?
a condition that occurs when the vein wall and/or valves in the leg veins do not work effectively, which impairs the ability for blood to return to the heart from the legs, resulting in venous-stasis
What are the 3 systems the chronic venous insufficiency divides into?
superficial (lesser and greater saphenous)
Deep (anterior and posterior tibial, peroneal, popliteal, deep femoral, superficial femoral, and iliac veins)
perforating or communicating veins
What can cause chronic venous insufficiency?
vein wall degeneration, post-thrombotic valvular damage, chronic venous obstruction, or dysfunction of the muscular pumps
What is edema?
How does it develop?
clinically apparent increase in the interstitial fluid volume
develops when starling forces are altered so that there is increased flow of fluid from the vascular system into the interstitium
What is the 4 point system used to classify pitting edema?
1+=barely detectable impression when finger is pressed into the skin
2+=slight indentation that takes 15 sec. to rebound
3+=deeper indention that takes 30 sec. to rebound
4+=takes over 30 seconds to rebound
What are the 3 main types of Ulcers?
Venous-maleolar location (usually medial) with irregular margins and browning around skin, usually also has varicose veins and pitting edema
Arterial-dorsal or distal locations (toes), sharp margins, painful, pallor and loss of hair are common
Neuropathic-plantar location, “punched out” margins, usually correspond to pressure point, may have arterial insufficiency signs and symptoms
True or False: edema is typical with arterial pathologies not typical with venous or lymph pathology
False-exact opposite of that, it is typical in venous and lymph pathologies but not typical in arterial
How do patients usually report their pain when they have intermittent claudication?
cramping type pain (which is due to ischemia) that gets better with rest and not typically “burning”
- pain is usually in the calves but can be higher on lower extremity
- pain correlates w/ area of obstruction: hip and buttock=aorto-iliac occlusion, thigh pain=iliofemoral occlusion, prox 2/3 of calf=superficial femoral artery, distal 1/3 calf=popliteal artery, foot=tibial artery
True or False:
Elevation will usually lessen symptoms in venous disorders but increase symptoms in arterial disorders.
Skin temperature will be warm for arterial disorders.
Limb size will increase due to swelling in venous disorders but decrease due to muscle wasting in arterial disorders.
True
False, it will be cool
True
How can you interpret Wells Score for DVT?
score higher than 2=high probability (53%)
score between 1 and 2=moderate probability (17%)
Score less than 1- low probability (5%)
if score is moderate to high then a vascular ultrasound is indicated
How can you interpret Wells Score for Pulmonary Embolism (PE)?
score higher than 6=high probability
score between 2 and 6=moderate probability
score below 2=low probability
if there is a score over 4 then PE and diagnostic imaging should be considered
If score is lower than 4 consider using D-dimer to rule out PE
True or False: roughly 1 in every 4 deaths annually is due to heart disease
True
What is ischemia?
What can increase O2 demand?
What can cause decreased O2 supply?
Condition of imbalance between myocardial O2 supply and demand often cause by atherosclerosis of the coronary arteries
exercise, cold weather, mental/emotional stress, spontaneous changes in HR and BP
impaired aortic driving pressure, increased coronary resistance
What causes an ischemic contracture of the myocardium?
insufficient or no ATP delivered to break cross myofilament cross-bridge
What is Angina?
What are the 3 major types?
Chest pain or discomfort caused due to cardiac ischemia (heaviness, tightness, pressure, or discomfort that gradually builds and subsides gradually)
Stable
Unstable
Printzemental
True or False: Somatic fiber pain is usually easily described and precisely located while visceral pain fibers come from internal organs and can refer to other parts of the body making them hard to describe or locate
True
What is the difference between stable and unstable angina?
stable-discomfort gradually builds, occurs w/ exercise at a predictable and consistent intensity, gradually subsides w/ rest, typically lasts 2-5 mins, improves with nitroglycerin
Unstable-recent or acceleration of angina threshold; new onset less than 2 months, symptoms at rest over 15-20 mins, gradually worsens in a crescendo like pattern, may not respond to nitro or rest, often a precursor to MI
What is a myocardial infarction (MI)?
cell death in the heart muscle caused by complete and prolonged occlusion of a coronary artery
What are the 3 main factors that increase the likelihood of MI?
Pain is associated with exertion
pain radiates to left arm
pain is described as pressure
What factors decrease the likelihood of MI?
- pain described as positional
- pain described as sharp
- pain reproducible w/ palpation
- pain not associated w/ exertion
